HEALTH CARE ASSOCIATED INFECTIONS AND ITS CONTROL Prof Victor Lim International Medical University

DefinitionDefinition Any infection acquired by patients or members of staff while in a heath care settingAny infection acquired by patients or members of staff while in a heath care setting Does not include infections which manifest in a health care setting but acquired outside the health care settingDoes not include infections which manifest in a health care setting but acquired outside the health care setting Includes infections acquired in a health care setting but manifest after dischargeIncludes infections acquired in a health care setting but manifest after discharge HEALTH CARE ASSOCIATED INFECTION

NOSOCOMIAL OR HOSPITAL ACQUIRED INFECTION Old term Nosocomium = Hospital Increasing day-care and ambulatory care in modern medical practice Chronic care facilities, nursing homes Confining definitions to hospitals only may not reflect the true situation Infection control is also important in non-hospital settings – hence health- care associated infections

History of Nosocomial Infection Ignaz Semmelweis, (1840s) demonstrated importance of hand hygieneIgnaz Semmelweis, (1840s) demonstrated importance of hand hygiene No progress for next centuryNo progress for next century 1976, the Joint Commission on Accreditation of Healthcare Organizations - standards for infection control1976, the Joint Commission on Accreditation of Healthcare Organizations - standards for infection control Nosocomial infection still on the increase - emerging infectionNosocomial infection still on the increase - emerging infection

Reasons for Re-emergence Antibiotic resistance : HCAI becoming more difficult to treatAntibiotic resistance : HCAI becoming more difficult to treat Increased numbers of vulnerable patientsIncreased numbers of vulnerable patients –progress in medical management –increasing day-care & ambulatory care Failure of staff to comply with infection control proceduresFailure of staff to comply with infection control procedures

Virtually all microorganisms can cause nosocomial infectionsVirtually all microorganisms can cause nosocomial infections VirusesViruses BacteriaBacteria FungiFungi ParasitesParasites CAUSES OF HCAI

BacteriaBacteria Gram +Gram + –Staphylococcus aureus –Staphylococcus epidermidis Gram -Gram - –Enterobacteriaceae –Pseudomonas aeruginosa –Acinetobacter baumanni Mycobacterium tuberculosisMycobacterium tuberculosis BACTERIA

VirusesViruses –Blood borne infections : HBV, HCV, HIV –Others: CMV, rubella, varicella, SARS FungiFungi –Candida –Aspergillus NOSOCOMIAL PATHOGENS

SOURCES OF INFECTION Endogenous source is the normal flora or colonisers of skin and other epithelial surfaces Exogenous other persons (cross-infection) inanimate objects (fomites)

SPREAD OF INFECTONS Air-borne Skin scales, droplet nuclei ContactDirect Hands & clothing Droplet contact followed by autoinoculation Clinical equipment Indirect Bedpans, bowls, jugs, etc

SPREAD OF INFECTONS The hands are the most important vehicle of transmission of HCAI

National NI prevalence rates : Ministry of Health and Teaching Hospitals

Common infectionsCommon infections –Urinary tract infections –Surgical wound infections –Lower respiratory infections –Traumatic wounds and burns infections –Primary bacteraemia TYPES OF INFECTIONS

Types of infections : National Surveillance Percentage

COST OF INFECTIONS United Kingdom 115 million pounds (1988) United States of America 5 billion dollars (1987) 4.5 billion dollars (1995) Malaysia???

CONTROL OF HCAI Hand hygiene is the single most important measure for control of nosocomial infections

TYPES OF HAND HYGIENE PROCEDURES Hand washing –Hand washing is usually limited to hands and wrists –Hands are washed for a minimum of 10 – 15 seconds with soap (plain or antimicrobial) and water –Transient micro-organisms are mechanically removed by rinsing. Hand antisepsis/decontamination –Hand antisepsis removes or destroys transient micro-organisms and confers a prolonged effect. –Two ways: »Wash hands and forearms with antimicrobial soap and water, for seconds »Decontaminate hands with a waterless, alcohol-based hand gel or hand rub for seconds. Appropriate for hands that are not soiled with protein matter or fat.

TYPES OF HAND HYGIENE PROCEDURES Surgical hand antisepsis –Removes or destroys transient micro- organisms and confers a prolonged effect. –Hands and forearms are washed thoroughly with an antiseptic soap for a minimum of 2-3 minutes. –Hands are dried using a sterile towel. –Required before performing invasive procedures.

HAND WASHING TECHNIQUE Source: World Health Organization. Regional Office for Western Pacific.

COMPOUNDS FOR HAND ANTI-SEPSIS Recommended by WHO –2%-4% chlorhexidine, –5%-7.5% povidone iodine, –1% triclosan, or –70% alcoholic hand rubs.

WHO FIRST GLOBAL PATIENT SAFETY CHALLENGE Clean care is safer care Alcohol-based hand rubs must be available at the point of care As effective as washing with soap or antiseptic and water More convenient and less time consuming

THE SWISS EXPERIENCE A hand hygiene campaign was launched in January 2006, in 116 hospitals nationwide. Alcohol-based hand rubs were available at the patient bedside or carried by staff in their pocket. Overall hand hygiene compliance increased from 54% to 68% - a 25% boost in patient safety. Nurses’ compliance is 72%. Doctors’ compliance showed an increase of 33% to an encouraging 60% Prevented 17,000 infections and saved CHF 60 million nationwide. Hand rubbing now accounts for up to 97% of all hand hygiene actions in Swiss hospitals Source : WHO

OTHER MEASURES Practise aseptic techniques when performing procedures Limit the duration of in-situ catheters (urinary and intravascular) to shortest possible Meticulous care of lines, ventilator tubing, catheters and wounds

OTHER MEASURES Isolation of infectious patients and immuno- compromised patients –Source isolation –Protective isolation –Use of single rooms with bathroom attached –Use of positive or negative pressure rooms Protect yourself appropriately through good practices and using personal protective equipment (STANDARD PRECAUTIONS)

PRACTISE STANDARD PRECAUTIONS

PROTECT YOURSELF THROUGH IMMUNISATION ImmunisationBCG Hepatitis B TetanusRubellaVaricellaInfluenza

CONCLUSIONS Preventing HCAI is a very important aspect of patient safety All health care personnel must practise the highest standards of infection control as HCAIs –Cause significant morbidity and mortality to patients and health care staff –Contribute to increasing prevalence of antibiotic resistance –Are difficult and expensive to manage –Can result in medical litigation